The Whole Story of the Patient’s Heart
Bill Hinchberger | 17-03-2017
Of all structural heart diseases, mitral valve insufficiency is the most prevalent. In the U.S., around one in ten people over the age of 75 suffer from mitral regurgitation.1 Interventional approaches to treating this condition have developed dramatically. This is due in part to advanced minimally invasive techniques enabled by improved diagnosis and planning based on highly accurate multimodality imaging. Three- and four-dimensional imaging plays an important role in patient selection for therapy planning, as well as during the procedure.
Live information on cardiac anatomy and function enable optimal device placement. Combined with the immediate feedback on the status of the device placement, imaging supports optimal patient outcomes. In Bordeaux, state-of-the-art Siemens Healthineers ultrasound technology and valve analysis software are revolutionizing the treatment of valvular disease – as Stéphane Lafitte, MD, explains.
Stéphane Lafitte, Head of Echocardiography at the Haut-Lévêque, a Cardiology Hospital on the outskirts of the city of Bordeaux in southwestern France, ranks among the world’s most renowned researchers in the field of echocardiography. His heart remains, however, firmly in clinical practice – which helps to explain why he specialized in echocardiography in the first place: “I wanted to have the best possible contact with patients, their patient history, and medical history.” The eminent cardiologist makes a distinction between his work and that of a radiologist, whom he characterizes as focused to a greater extent on the images themselves. “Being a physician is important to me. To be close to the patient was really my first motivation,” says Lafitte, who doubles as Professor of Cardiology at Bordeaux Hospital University Center (CHU).
See the heart as never before
Lafitte’s interactions with valvular disease patients at his clinical practice are increasingly enhanced by an innovative ultrasound system focused on echocardiography. ACUSON SC2000™ PRIME integrates two new state-of-the-art technologies. The first is a True Volume transesophageal echocardiography (TEE) probe providing detailed real-time, 3D volume color Doppler images of the heart anatomy, function, and – bringing a new perspective to 3D echocardiography – blood flow. In conjunction, the eSie Valves analysis software automatically provides data on heart valves in seconds. “You have a chance to see the heart as never before,” Lafitte remarks. To witness the system in action is breathtaking, but Lafitte cares more about the practical implications. With real-time 3D echocardiography, physicians can personalize treatments and better plan and perform surgeries as well as other, less invasive cardiac procedures. “It gives you information that can significantly increase patient outcomes in cardiology by enabling a thorough and true understanding of the heart and providing guidance and feedback in real time. That’s why I am so enthusiastic,” says Lafitte.
Other ultrasound systems that feature 3D TEE probes depend on image stitching, the combination of data from multiple heartbeats to create a virtual, roughly-calculated composition. Therefore, this technique can result in errors, especially in patients with irregular heartbeats. By contrast, the Siemens Healthineers solution acquires the relevant information within a single heartbeat. This enables echocardiographers to provide real-time clinical guidance for arrhythmia patients for the first time. “You have to understand why we need one-beat acquisition, or what we call realtime 3D acquisition, as opposed to multi-beat, stitch acquisition,” Lafitte says. “With real-time imaging, the information you need flows by the milli-second,” he continues, “but if you have a system where you have to wait one, two, or several seconds to get this information, you lose the ability to guide interventional cardiology in true real time.” “We are now focusing on valvular diseases,“ Lafitte explains. “In this field, patients today have treatment options where procedures can be performed without opening the thorax. We use intravascular devices to replace or repair heart valves. We believe ACUSON SC2000 PRIME is the best for real-time imaging with volume color Doppler,” he adds. “Volume color Doppler helps us to visualize leaks in the valve in real time with a volumetric representation; this allows us for example to deploy, reposition one or more MitraClips very easily.”
“Previously, we used X-ray only to guide us in cardiac inter-ventions,” Lafitte adds. “But to guide implantations of MitraClip or future TMVI (transcatheter mitral valve implantation) devices, ultrasound may become the primary imaging technique. In these procedures, interventional cardiologists and cardiac surgeons are desperate for real-time information on the changes in function and flow that can be provided by the 3D TEE probe. In addition, anatomical information and crucial measurements to prepare and guide procedures can be provided by the eSie Valves software. That’s why the SC2000 provides one of the best solutions,” he says. With the new Siemens Healthineers system’s improved speed, ease of use, and quality of results, 3D transesophageal echocardiography brings new insights as a specialty procedure and entered the mainstream as a standard tool. “It can be used to look at heart anatomy, heart structure, strain and flow, and give clinically relevant measurements on a par with information provided by other imaging modalities,” Lafitte explains. “It helps provide a better understanding of pathologies, of course, and in treating patients.” Notably, he adds, this benefits his area of specialization – valvular disease.
Before starting at CHU Haut-Lévêque, Stéphane Lafitte studied with some of the top names in the profession, including Raymond Roudaut in France, who inspired him to take up teaching, and Anthony DeMaria at the University of California, San Diego. In the United States, Lafitte first began to work with medical equipment manufacturers on research projects. Returning to France, he was soon combining experiences from his clinical practice with his scholarly interests. “My main research focus was in ultrasound technology,” he notes. “I validated, or ‘invalidated,’ many innovations in the last two decades.” His research interests never strayed very far from the foundation of his clinical work with patients. “I tried to link images to understanding the function of the heart,” he says. “This connection is the most important thing.” This placed him well to be one of the early adopters of the ACUSON SC2000 PRIME system. With over 250 beds in its cardiology wing, CHU Haut-Lévêque boasts eight rooms for echocardiography alone. It made sense for the hospital to be one of the first ACUSON SC2000 customers.
When the system came on the market in 2009, it offered novel technological solutions, but some features were not yet fully implemented – notably in terms of the software tools needed for good three-dimensional images and their manipulation. At the same time, 3D transesophageal echocardiography was developed. “When we started to work with this new technology, 3D TEE was still in its infancy,” Lafitte recalls, adding that it “needed to mature.” “When I first got to work with the ACUSON SC2000, the system offered some new features, especially to describe ventricular mechanics,” he adds. “The software was quite exciting for research purposes. The approach to understanding heart motion – that was very new. But it needed some time before it could be used in clinical practice. Still, we were confident it was the right platform.” With his dual responsibility as a physician and university researcher, Lafitte was in a strong position to make suggestions about improvements. And Siemens was listening. “It improved, year after year. It was incredible,” he says.
The ACUSON SC2000 PRIME Ultrasound system provides detailed real-time, 3D volume color Doppler images of the heart anatomy, function, and blood flow. This enables cardiologists to guide procedures more precisely by providing live information at crucial points during the intervention that may have a direct impact on the outcome. The analysis software eSieValves provides automated measurement and modeling on a par with the gold standard of cardiac CT measurements.
Proof is in the detail
About a year ago, after Siemens engineers had developed their own TEE probe, Lafitte conducted thorough tests of the system. He liked what he found. “It’s probably the best on the market,” he concludes. Lafitte hands out praise in small doses. And he is very keen on preserving his academic freedom. His salary and funding do not depend on grants from donors. “I’m totally free to choose my research subjects and partners for collaboration,” he says. “If a system doesn’t work, I can be honest and tell the company that.” In his work with Siemens Healthineers, he found the company very receptive to his suggestions.
Then there is always Lafitte’s symbiosis of research and clinical work. He can always call upon real-life examples to illustrate his broader points. For instance, in the case of transcatheter mitral valve repair (TMVR) with a MitraClip device, comprehensive knowledge of the flow dynamics is needed to optimize the reduction in mitral regurgitation. “Siemens’s real-time 3D color acquisition is very helpful when you need to be sure that you have placed the clip in the right position,” he says. “When you clip the valve, you see the decrease in leakage. If it isn’t enough, you can add another clip or move the position of the first. The only way to do that is to have a volumetric representation of the leak. Which means 3D, usually with TEE, and 3D realtime color Doppler.” Then there is the time he needed to see the indentations of the mitral valve. A mitral valve is “a virtual space in an open valve that disappears when it is closed,” he explained. “Before putting in a MitraClip to close it, you have to know whether you have a deep indentation or not. In one patient, we observed a deep indentation that could be seen only with 3D. We stopped the procedure for the patient’s benefit.”
Across the board
Although Lafitte can be understated in his praise, when asked to outline the advantages of the ACUSON SC2000 PRIME system, his list is exhaustive: image quality in acquisition, visualization, ease of adaption of images, workflows, automated measurements, valve modeling, and more. “Other companies came to the market with a 3D acquisition system,” he says. “But acquisition is just one element. We need to have both images and calculations for the right treatment. If one of these parts is missing, you won’t get clinically useful information with actual added value.” In Lafitte’s view, the ACUSON SC2000 PRIME brings all those elements together. “It is really the first system in the world to combine all of these parts, allowing for 3D transesophageal echocardiography to enter practical routine.” The benefits are evident – across the board.
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